• Certification and Ongoing Responsibilities
  • Introduction
  • Other Facilities
  • Responsibilities
  • Supervision Requirements
    • Introduction
    • Declaration of Supervision
    • Supervision Waiver
  • Durable Medical Equipment and Disposable Medical Supplies
• Provider Communication
  • Introduction
  • Coordination with School-Based Services Providers
  • Coordination with County Birth to 3 Programs
  • Therapy Services for Children Brochure
  • Guide to Obtaining Augmentative Communication Devices and Accessories
  • Directory of Used Medical Equipment
• Documentation Requirements
  • Introduction
  • Prescriptions
  • Evaluations
  • Plan of Care
  • Daily Entries
• Services and Requirements
  • Introduction
  • Initial Spell of Illness
  • Daily Limitations
  • Duplicate Services
  • Evaluations
  • Group Therapy
  • Natural Environments
  • Durable Medical Equipment and Disposable Medical Supplies
  • HealthCheck "Other Services"
  • Services Not Separately Reimbursable
  • Reimbursement Not Available
• Codes
  • Procedure Codes
    • Introduction
    • Unit of Service
  • Modifiers
  • Place of Service Codes
  • Diagnosis Codes
• Prior Authorization
  • Introduction
  • Prior Authorization Forms and Attachments
  • Medical Necessity
    • Introduction
    • Relationship of Medical Necessity to Clinical Practice Principles
  • Flexibility of Approved Services
    • Introduction
    • Plan of Care Must Reflect Flexibility of Approved Services
    • Duration of Approved Services
    • Coordinating Multiple Prior Authorization Requests
• Requesting Extension of Therapy, Maintenance Therapy, and Services That Always Require Prior Authorization
  • Introduction
  • Approval Criteria
  • Extension of Therapy
  • Maintenance Therapy
    • Introduction
    • Direct Maintenance
    • Monitoring Maintenance
    • Discontinuing Maintenance
  • Services That Always Require Prior Authorization
    • Introduction
    • Cotreatment
    • Dual Treatment
    • Unlisted Procedure Codes
    • Decubitus Ulcers
• Requesting Spell of Illness
  • Introduction
  • Maximum Allowable Treatment Days
    • Introduction
    • Unused Treatment Days
• Extension of Therapy vs. Spell of Illness
• Requesting Services for Birth to 3 Participants
  • Introduction
  • Situations That Do Not Qualify for Birth to 3
• Requesting Amendments
  • Introduction
  • Approval Criteria
  • Reasons for Denial
• Claims
  • Introduction
  • 837 Health Care Claim: Professional
  • CMS 1500
  • Provider Numbers
    • Individual Providers
    • Groups, Clinics, and Nursing Homes
    • Rehabilitation Agencies
    • Hospitals
  • Referring Provider
  • Evaluations
  • Services Provided Beyond Daily Limits
  • Unlisted Procedure Codes
  • Multiple Services During One Session
  • Submitting Claims for Birth to 3 Services
• Reimbursement
  • Maximum Allowable Fees
  • Reimbursement Methods
    • Introduction
    • Natural Environment Enhanced Reimbursement
  • Copayment
    • Introduction
    • Annual Copayment Maximum
• Appendix
• PDF

Claims

CMS 1500

Paper claims for PT, OT, and SLP services must be submitted using the CMS 1500 claim form dated 12/90. Wisconsin Medicaid denies claims for PT, OT, and SLP services submitted on any paper claim form other than the CMS 1500.

Wisconsin Medicaid does not provide the CMS 1500 claim form. The form may be obtained from any federal forms supplier.

Refer to Appendix 34 of this handbook for claim form instructions for PT, OT, and SLP services. Appendices 35, 36, and 37 of this handbook are samples of claims for PT, OT, and SLP services.

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Previous — Claims, 837 Health Care Claim: Professional